4 What are the plans for follow‐up care?
5 What health education should be provided to this patient?
6 Are there any standardized guidelines that should be used to treat this case? If so, what are they?
Case 6.5 Vaginal Itching
By Sara Smoller, RN, MSN, ANP‐BC
SUBJECTIVE
Martha is a 24‐year‐old female who reports vaginal itching for 3 days. She says that she can barely focus on other things because of the itching. She also reports a copious, white vaginal discharge. Her last Pap smear was at age 22 and was negative. She has not received the HPV vaccine series. Martha denies previous episodes and states that she is otherwise healthy. She denies fever, chills, nausea, vomiting, or diarrhea. She is sexually active with both male and female partners since the age of 15. She states that recently she has been exclusively with females but has had 2 sexual partners in the past year. She states that she still feels somewhat confused about her sexual preferences. She admits to dyspareunia and burning with urination. She denies use of vaginal sprays, douches, or powders or the use of new soaps, detergent, or clothing. Her last menstrual period (LMP) was 3 weeks ago.
Past medical history: Recurrent strep pharyngitis—last episode 3 weeks ago.
Family history: Remarkable for diabetes mellitus and COPD.
Social history: Martha is a college graduate and still lives with her widowed mother. She feels safe and has a good relationship with her mother but has not disclosed her sexual preferences to her mother. Martha does worry about their financial status as she and her mother have low‐paying jobs and do not have other financial support. They are currently renting their apartment from a friend. Martha does not smoke and denies substance use.
Medications: None currently. She completed a 10‐day course of amoxicillin 1 week ago for strep pharyngitis.
Allergies: Seasonal in spring.
OBJECTIVE
Vital signs: Martha is afebrile. Her BP is 110/70. Pulse is 64 and regular. Respirations are 12 and unlabored. She is 5 ft 3 inches tall and weighs 120 lbs.
General: Martha is pleasant and cooperative but seems anxious about the visit.
Throat: No swelling or exudates.
Cardiac: Regular rate and rhythm.
Respiratory: Lungs are clear bilaterally.
Abdomen: Soft, nontender, nondistended, and without organomegaly.
Pelvic exam: Inguinal lymph nodes are without swelling or tenderness; vaginal mucosa is moist, pink, and mildly swollen. There is no foul odor; but there is a white, cottage cheese–like discharge at the introitus. The cervix is pink and without friability. There is no cervical motion tenderness (CMT). The pH of the vaginal discharge is within normal range (3.8–4.2).
CRITICAL THINKING
1 Which diagnostic or imaging studies should be considered to assist with or confirm the diagnosis?___Pap smear___Cultures for gonorrhea and chlamydia___Urine testing for gonorrhea and chlamydia___Wet mount, including KOH and whiff test___Urinalysis
2 If a wet mount were performed, what findings would be expected for the following diagnoses?Bacterial vaginosisCandidiasisTrichomonas
3 What is the most likely differential diagnosis and why?___Bacterial vaginosis___Candidiasis___Trichomonas___Gonorrhea___Chlamydia___Herpes simplex___Urinary tract infection
4 What is the plan of treatment?
5 What education should be provided to Martha at this visit?
6 Are any referrals needed?
7 Is the family history of diabetes relevant to this case?
8 How can the clinician support the patient regarding her confusion with her sexual preferences?
NOTE: The author would like to thank Leslie Neal‐Boylan, PhD, APRN, CRRN, FAAN, FARN for her contribution to this case in the first edition of this book.
Case 6.6 Redness and Swelling in the Breast
By Karen M. Flaherty, MSN, MEd, APRN‐BC, CBCN
SUBJECTIVE
Jill is a 26‐year‐old female who presents today for evaluation of redness, swelling, and pain in her right breast. Three months ago she underwent bilateral nipple piercings while on vacation in the Caribbean. Both sites had healed well until 4 days ago, when she noted “mild” redness on her right lower breast. This has increased in size and depth of color and she began experiencing swelling and pain in the right breast. Last night she noted a small amount of drainage on the right side of bra and felt mildly feverish.
Past medical history: Jill is an otherwise healthy 26‐year‐old female of Ashkenazi Jewish heritage who had the usual childhood illnesses. Her immunizations are up to date. She’s had no chronic illnesses and has no past surgical history.
Family medical history: Jill’s mother and father (Ashkenazi Jewish) are alive and well. She has 2 brothers, ages 20 and 18, with no significant medical problems. Her paternal grandmother is age 67 and has Type 2 diabetes mellitus; she was treated for left breast cancer at age 43 and tested positive for the BRCA 1 and 2 gene. Jill’s paternal grandfather is age 70 and is alive and well. Her maternal grandmother is age 65 and has high blood pressure; her maternal grandfather is age 67 and alive and well.
Social history: Jill graduated with a degree in art and works as an assistant in an art gallery; she is applying to graduate school. Jill lives in Boston with a female roommate. Her alcohol intake includes 2–3 glasses of wine on the weekend. She has been smoking 3–4 cigarettes per day since age 20. She performs Pilates 2–3 times per week.
Medication: Daily BCP, MVI, Tylenol if needed for headache.
Allergies: Seasonal sllergies (spring), penicillin (rash and hives).
OBJECTIVE
General: Pleasant young woman, who appears mildly unwell, in moderate discomfort; rates pain 4/10 located in R breast.
Vital signs: Temperature: 100.4°F; P: 90; BP: 100/60.
Cardiac: Rate 96 and regular, no murmurs heard on auscultation.
Respiratory: Rate 16 breaths per minute, lungs clear to auscultation in all lobes.
Skin: Face is flushed. Right breast has marked redness and warmth over the lower half, left breast no redness or increase in temperature.
Breast: Right breast is slightly swollen, with erythema extending over the lower half of the right breast, central area of induration within the area of erythema. Mild skin thickening and edema noted. There is a ring piercing through the right nipple, no drainage seen. Right breast has a tender area of induration within the central portion of the erythema. No other discrete or dominant masses found. No observable drainage seen from right breast. Left breast has a ring piercing through the left nipple, no swelling, erythema, or induration, also with piercing through the left nipple. Left breast is smooth to